2020 comprehensive formulary - aetna · 8/1/2020 · coverage of the drug during the 2020 coverage...

2020 Comprehensive

Formulary

Aetna Better Health of Virginia(List of Covered Drugs) B2PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION

ABOUT THE DRUGS WE COVER IN THIS PLAN.

This formulary was updated on 11/01/2020. For more recent information or other questions, please contact Aetna Better Health of Virginia Member Services at 1-855-463-0933

or for TTY users: 711, 24 hours a day, 7 days a week, or visit https://www.aetnabetterhealth.com/virginia-hmosnp/formulary.

Formulary ID Number: 20174 Version 21

NR_1085_16669_C_ Final_ 6 07/2019 20174AETVA

https://www.aetnabetterhealth.com/virginia-hmosnp/formulary

Table of contents

Mail-order Pharmacy 3

What is the Aetna Better Health of Virginia

Comprehensive Formulary? 4

Can the Formulary (drug list) change? 4

How do I use the Formulary? 5

What are generic drugs? 5

Are there any restrictions on my coverage? 5

What if my drug is not on the Formulary? 6

How do I request an exception to the Aetna Better Health of Virginia Formulary? 6

What do I do before I can talk to my doctor about changing my drugs or requesting an exception? 7

For more information 7

Aetna Better Health of Virginia Formulary 8

Drug tier copay levels 9

Formulary key 10

Drug list 10

Index of Drugs 99

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Aetna Better Health of Virginia is a HMO, PPO plan with a Medicare contract. Our SNPs also have contracts with State Medicaid programs. Enrollment in our plans depends on contract renewal.

Aetna Better Health of Virginia es un plan HMO, PPO con un contrato de Medicare. Nuestros Planes de necesidades especiales (SNP, por sus siglas en inglés) también tienen contratos con los programas estatales de Medicaid. La inscripción en nuestros planes depende de la renovación del contrato.

Members who get “Extra Help” are not required to fill prescriptions at preferred network pharmacies in order to get Low Income Subsidy (LIS) copays.

See Evidence of Coverage for a complete description of plan benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by service area.

Mail-order Pharmacy For mail order, you can get prescription drugs shipped to your home through the network mail-order delivery program. Typically, mail-order drugs arrive within 7 to 14 days. You can call 1-855-463-0933 (TTY: 711) 24 h ours a day, 7 d ays a week, if you do not receive your mail-order drugs within this timeframe. Members may have the option to sign up for automated mail-order delivery.

ATTENTION: If you speak Spanish or Chinese, language assistance services, free of charge, are available to you. Call the number on your ID card.

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al número que figura en su tarjeta de identificación.

注意：如果您使用中文，您可以免費獲得語言援

助服務。請撥打您的會員身分卡上的電話號碼。

Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us”, or “our,” it means Aetna Better Health of Virginia. When it refers to “plan” or “our plan,” it means Aetna.

This document includes a list of the drugs (formulary) for our plan which is current as of 11/01/2020. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2021, and from time to time during the year.

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What is the Aetna Better Health of Virginia Comprehensive Formulary? A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Aetna Better Health of Virginia network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary (drug list) change? Most changes in drug coverage happen on January 1, but we may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow Medicare rules in making these changes.

Changes that can affect you this year: In the below cases, you will be affected by coverage changes during the year:

• New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made.

° If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Aetna Better Health of Virginia Formulary?”

• Drugs removed from the market. If the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.

• Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to the market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug.

° If we make these other changes, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Aetna Better Health of Virginia Formulary?”

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Changes that will not affect you if you are currently taking the drug.

Generally, if you are taking a drug on our 2020 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2020 coverage year except as described above. This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year.

The enclosed formulary is current as of 11/01/2020. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages.

In the event of any CMS-approved, mid-year non-maintenance formulary changes, the formularies will be updated monthly and posted on our website.

How do I use the Formulary? There are two ways to find your drug within the formulary:

Medical Condition The formulary begins on page 10. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Agents”. If you know what your drug is used for, look for the category name in the list that begins on page 10. Then look under the category name for your drug.

Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 99. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs? Our plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don’t get approval, we may not cover the drug.

• Quantity Limits: For certain drugs, our plan limits the amount of the drug that we will cover. For example, our plan provides 30 tablets per 30 days per prescription for candesartan. This may be in addition to a standard one-month or three-month supply.

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• Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 10. You can also get more information about the restrictions applied to specific covered drugs by visiting our Website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy.

Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask us to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Aetna Better Health of Virginia formulary?” on page exception page 6 for information about how to request an exception.

What if my drug is not on the Formulary?

If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered.

If you learn that our plan does not cover your drug, you have two options:

• You can ask Member Services for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan.

• You can ask us to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the Aetna Better Health of Virginia Formulary? You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

• You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

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You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request.

Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception.

If you experience a change in your setting of care (such as being discharged or admitted to a long term care facility), your physician or pharmacy can request a one-time prescription override. This one-time override will provide you with temporary coverage (up to a 30-day supply) for the applicable drug(s).

For more information For more detailed information about your plan’s prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about our plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

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http://www.medicare.gov

Aetna Better Health of Virginia Formulary

The comprehensive formulary that begins on page 10 provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 99.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LEVEMIR) and generic drugs are listed in lower-case italics (e.g., candesartan).

The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug. The following abbreviations are used:

QL Quantity Limits

PA Prior Authorization

ST Step Therapy

LA Limited Access

MO Mail-order Delivery

B/D Part B vs. D Prior Authorization

QL: Quantity Limits. For certain drugs, our plan limits the amount of the drug that we will cover. For example, our plan provides 30 tablets per 30 days per prescription for candesartan.

PA: Prior Authorization. Our plan requires you or your provider to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don’t get approval, we may not cover the drug.

ST: Step Therapy. In some cases, our plan requires you to first try certain drugs to treat your medical condition, before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

LA: Limited Access. These prescriptions may be available only at certain pharmacies. For more Information, consult your Pharmacy Directory or call Aetna Member Services at 1-855-463-0933 (TTY: 711), 24 hours a day, 7 days a week.

MO: Mail Order. For certain kinds of drugs, you can use CVS Caremark® Mail Service Pharmacy. Generally, the drugs available through mail order are drugs that you take on a regular basis, for a chronic or long-term medical condition. The drugs available through our plan’s mail-order service are marked as “MO” in our Drug List. For more information, consult your Pharmacy Directory or call Aetna Member Services at 1-855-463-0933 (TTY: 711), 24 hours a day, 7 days a week.

B/D: Part B versus Part D. This prescription drug has a Part B versus Part D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

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Drug tier copay levels

This 2020 comprehensive formulary is a listing of brand-name and generic drugs. Aetna Better Health of Virginia’s 2020 formulary covers most drugs identified by Medicare as Part D drugs, and your copay may differ depending upon the tier at which the drug resides.

The copay tiers for covered prescription medications are listed below. Copay amounts and coinsurance percentages for each tier vary by Aetna Better Health of Virginia plan. Consult your plan’s Summary of Benefits or Evidence of Coverage for your applicable copays and coinsurance amounts.

Copay tier Type of drug

Tier 1 Preferred Generic

Tier 2 Generic

Tier 3 Preferred Brand

Tier 4 Non-Preferred Drug

Tier 5 Specialty

Our plan combines higher cost generic drugs on brand tiers. Refer to the drug list to determine the tier of coverage for each drug you take.

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*You can find information on what the symbols and abbreviations on this table mean by going to page 8.

0

Key* Drug name Drug tier Requirements/Limits

UPPERCASE = Brand-name prescription drugs

Lowercase italics = Generic medications

1, 2, 3, 4, 5 = Copay tier level

QL = Quantity Limit PA = Prior Authorization ST = Step Therapy LA = Limited Access MO = Mail-order Delivery B/D = Part B vs. Part D

Drug name Drug tier Requirements/Limits ANALGESICS

Nonsteroidal Anti-inflammatory Drugs CAMBIA 4 PA MO celecoxib caps 400mg 3 QL (30 EA per 30 days) MO celecoxib caps 100mg, 200mg, 50mg 3 QL (60 EA per 30 days) MO diclofenac potassium 2 MO diclofenac sodium dr 2 MO diclofenac sodium er 2 MO diclofenac sodium/misoprostol 4 MO diflunisal tabs 500mg 4 MO DUEXIS 4 MO etodolac er 4 MO etodolac caps, tabs 3 MO fenoprofen calcium caps 400mg 4 MO fenoprofen calcium tabs 4 MO flurbiprofen tabs 2 MO ibuprofen susp 2 MO

ibuprofen tabs 400mg, 600mg, 800mg

2 MO

ibu tabs 600mg, 800mg 2 ketoprofen er cp24 200mg 4 MO ketoprofen caps 50mg, 75mg 4 ketoprofen caps 25mg 4 MO

ketorolac tromethamine inj 15mg/ml, 30mg/ml, 60mg/2ml

4 QL (20 ML per 30 days) PA MO

ketorolac tromethamine tabs 10mg 2 QL (20 EA per 30 days) PA MO meclofenamate sodium caps 4 MO meloxicam tabs 1 MO nabumetone tabs 2 MO naproxen dr tabs 375mg, 500mg 2 MO

1


naproxen sodium cr tabs 375mg 4 MO naproxen sodium er tb24 500mg 4 MO naproxen sodium tabs 275mg, 550mg

2 MO

naproxen/esomeprazole magnesium tbec 20mg; 500mg

4 MO

naproxen/esomeprazole magnesium tbec 20mg; 375mg

5 MO

naproxen susp 2 MO naproxen tabs 250mg, 375mg, 500mg 1 MO oxaprozin 4 MO PENNSAID SOLN 2% 4 QL (224 GM per 28 days) PA MO piroxicam caps 3 MO profeno 4 sulindac tabs 2 MO VIMOVO TBEC 20MG; 500MG 4 MO VIMOVO TBEC 20MG; 375MG 5 MO

Opioid Analgesics, Long-acting buprenorphine transdermal patch 4 QL (4 EA per 28 days) PA MO fentanyl transdermal patch 4 QL (15 EA per 30 days) PA MO HYSINGLA ER 3 QL (30 EA per 30 days) PA MO methadone hcl tabs 3 QL (180 EA per 30 days) PA MO methadone hcl oral soln 3 QL (3000 ML per 30 days) PA MO methadone hcl conc 3 QL (360 ML per 30 days) PA MO methadone hcl inj 5 PA

morphine sulfate er cp24 (generic Avinza) 120mg, 30mg, 45mg, 60mg,

75mg, 90mg

4 QL (30 EA per 30 days) PA MO

morphine sulfate er cp24 (generic Kadian) 100mg, 10mg, 20mg, 30mg,

40mg, 50mg, 60mg, 80mg


morphine sulfate er tbcr 100mg, 200mg, 30mg, 60mg


morphine sulfate er tbcr 15mg 3 QL (90 EA per 30 days) PA MO NUCYNTA ER 3 QL (60 EA per 30 days) PA MO

tramadol hcl er cp24 100mg, 200mg, 300mg


tramadol hcl er tb24 100mg, 200mg, 300mg


Drug name Drug tier Requirements/Limits

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Opioid Analgesics, Short-acting acetaminophen/codeine tabs 3 QL (180 EA per 30 days) MO acetaminophen/codeine soln 3 QL (4500 ML per 30 days) MO butorphanol tartrate nasal soln 4 QL (5 ML per 30 days) MO butorphanol tartrate inj 1mg/ml 4 butorphanol tartrate inj 2mg/ml 4 MO codeine sulfate tabs 30mg 4 QL (180 EA per 30 days) codeine sulfate tabs 15mg, 60mg 4 QL (180 EA per 30 days) MO

endocet tabs 325mg; 10mg, 325mg; 2.5mg, 325mg; 5mg, 325mg; 7.5mg

3 QL (180 EA per 30 days)

fentanyl citrate oral transmucosal lozenge


hydrocodone bitartrate/ acetaminophen soln 325mg/15ml;

7.5mg/15ml

3 QL (5550 ML per 30 days) MO

hydrocodone bitartrate/ acetaminophen tabs 300mg; 10mg,

300mg; 5mg, 300mg; 7.5mg, 325mg; 2.5mg

3 QL (180 EA per 30 days) MO

hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 5mg, 325mg;

7.5mg


hydrocodone/ibuprofen tabs 10mg; 200mg, 5mg; 200mg, 7.5mg; 200mg


hydromorphone hcl tabs 3 QL (180 EA per 30 days) MO hydromorphone hcl liqd 4 QL (2400 ML per 30 days) MO hydromorphone hcl inj 10mg/ml 4 B/D hydromorphone hcl inj 1mg/ml, 2mg/ ml, 4mg/ml

4 B/D MO

hydromorphone hydrochloride pf inj 1mg/ml, 2mg/ml, 50mg/5ml

4 B/D

hydromorphone hydrochloride pf inj 4mg/ml

4 B/D MO

lorcet 4 QL (180 EA per 30 days) lorcet hd 4 QL (180 EA per 30 days) lorcet plus tabs 325mg; 7.5mg 4 QL (180 EA per 30 days) morphine sulfate tabs 3 QL (180 EA per 30 days) MO morphine sulfate inj 0.5mg/ml, 10mg/

ml, 150mg/30ml, 1mg/ml, 25mg/ml, 2mg/ml, 4mg/ml, 50mg/ml, 5mg/ml,

8mg/ml

4 B/D


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*You can find information on what the symbols and abbreviations on this table mean by going topage 8.

morphine sulfate pf inj 1mg/ml 4 B/D MO morphine sulfate oral soln 10mg/5ml 3 QL (1800 ML per 30 days) MO morphine sulfate oral soln 20mg/5ml 3 QL (900 ML per 30 days) MO

morphine sulfate oral soln 100mg/5ml


nalbuphine hcl inj 10mg/ml, 20mg/ml 3 MO oxycodone hcl caps 3 QL (180 EA per 30 days) MO oxycodone hydrochloride soln 3 QL (5400 ML per 30 days) MO oxycodone hcl oral conc 4 QL (180 ML per 30 days) MO oxycodone hydrochloride tabs 30mg 3 QL (120 EA per 30 days) MO

oxycodone hydrochloride tabs 10mg, 15mg, 20mg, 5mg


oxycodone/acetaminophen tabs 325mg; 10mg, 325mg; 2.5mg, 325mg;

5mg, 325mg; 7.5mg


oxycodone/aspirin tabs 325mg; 4.835mg


oxycodone/ibuprofen 3 QL (120 EA per 30 days) MO oxymorphone hydrochloride

immediate release tabs 4 QL (180 EA per 30 days) MO

tramadol hcl tabs 2 QL (240 EA per 30 days) MO tramadol hydrochloride/ acetaminophen


tramadol hydrochloride tabs 100mg 2 QL (120 EA per 30 days) MO vicodin es tabs 300mg; 7.5mg 4 QL (180 EA per 30 days) vicodin hp tabs 300mg; 10mg 4 QL (180 EA per 30 days) vicodin tabs 300mg; 5mg 4 QL (180 EA per 30 days)

ANESTHETICS Local Anesthetics

lidocaine hcl inj 0.5%, 1%, 1.5%, 2%, 4%

4

lidocaine hcl external soln 4% 4 MO lidocaine hydrochloride inj 1%, 2% 4 lidocaine viscous 4 MO lidocaine/prilocaine crea 4 QL (30 GM per 30 days) PA MO lidocaine oint 4 QL (35.44 GM per 30 days) PA

MO lidocaine ptch 5% 3 QL (90 EA per 30 days) PA MO


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ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS Alcohol Deterrents/Anti-craving

acamprosate calcium dr 4 MO disulfiram tabs 4 MO naltrexone hcl tabs 3 MO VIVITROL 5

Opioid Dependence Treatments buprenorphine hcl/naloxone hcl subl 2 QL (90 EA per 30 days) MO buprenorphine hcl subl 2 QL (90 EA per 30 days) PA MO buprenorphine hydrochloride/

naloxone hydrochloride film 12mg; 3mg


buprenorphine hydrochloride/ naloxone hydrochloride film 2mg;

0.5mg, 4mg; 1mg, 8mg; 2mg


Opioid Reversal Agents naloxone hcl cartridge 0.4mg/ml 2 naloxone hcl inj 4mg/10ml 2 MO naloxone hcl inj 2mg/2ml 3 naloxone hydrochloride inj 0.4mg/ml 2 MO NARCAN LIQD 3 MO

Smoking Cessation Agents bupropion hydrochloride er (sr) tb12

150mg 3 QL (60 EA per 30 days) MO

CHANTIX CONTINUING MONTH PAK 4 PA MO CHANTIX STARTING MONTH PAK 4 PA MO CHANTIX TABS 0.5MG, 1MG 4 PA MO NICOTROL INHALER 4 MO NICOTROL NS 4 MO

ANTIBACTERIALS Aminoglycosides

amikacin sulfate inj 1gm/4ml, 500mg/2ml

4 MO

gentamicin sulfate pediatric 4 MO gentamicin sulfate/0.9% sodium

chloride inj 1.2mg/ml; 0.9%, 1mg/ml; 0.9%, 2mg/ml; 0.9%

4

gentamicin sulfate/0.9% sodium chloride inj 1.6mg/ml; 0.9%

4 MO

gentamicin sulfate inj 40mg/ml 4 MO


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Drug name Drug tier Requirements/Limits isotonic gentamicin inj 0.8mg/ml; 0.9%

4 MO

neomycin tabs 2 MO paromomycin caps 4 MO streptomycin sulfate inj 1gm 4 MO tobramycin sulfate inj 1.2gm, 10mg/ ml, 40mg/ml

4

tobramycin sulfate inj 1.2gm/30ml, 80mg/2ml

4 MO

Antibacterials, Other chloramphenicol inj 1gm 4 clindamycin hcl caps 300mg, 75mg 2 MO clindamycin hydrochloride caps 150mg

2 MO

clindamycin palmitate hcl 4 MO clindamycin phosphate inj 900mg/6ml iv

4

clindamycin phosphate/dextrose 4 clindamycin phosphate crea 2% 4 MO clindamycin phosphate inj 300mg/2ml, 600mg/4ml iv, 9000mg/60ml iv

4

clindamycin phosphate inj 600mg/4ml, 900mg/6ml

4 MO

CLINDAMYCIN/SODIUM CHLORIDE 4 colistimethate inj 4 PA MO DAPTOMYCIN INJ 350MG 5 daptomycin inj 500mg 5 MO lansoprazole/amoxicillin/ clarithromycin


linezolid inj 4 PA linezolid tabs 4 QL (56 EA per 28 days) PA MO linezolid oral susp 5 QL (1800 ML per 28 days) PA MO MACROBID 4 MO methenamine hippurate 4 MO methenamine mandelate tabs 0.5gm, 1gm

4 MO

metronidazole vaginal 4 MO metronidazole caps 375mg 3 MO metronidazole inj 5mg/ml 4


15


metronidazole tabs 250mg, 500mg 3 MO nitrofurantoin macrocrystals 3 MO nitrofurantoin monohydrate 3 MO nitrofurantoin susp 4 MO SIVEXTRO INJ 5 SIVEXTRO TABS 5 MO SYNERCID INJ 350MG; 150MG 5 tigecycline 5 tinidazole 4 MO trimethoprim tabs 1 MO VANCOMYCIN 4

VANCOMYCIN HCL INJ 0.9%; 1GM/200ML

4

vancomycin hcl inj 100gm, 10gm 4 vancomycin hydrochloride caps

125mg 4 QL (120 EA per 30 days) MO

vancomycin hydrochloride caps 250mg


VANCOMYCIN HYDROCHLORIDE INJ 1.25GM, 1.5GM, 1250MG/250ML,

1750MG/350ML, 250MG, 500MG/100ML, 750MG/150ML

4

vancomycin hydrochloride inj 1gm, 5gm, 750mg

4

vancomycin hydrochloride inj 500mg 4 MO VANDAZOLE 4 MO XIFAXAN TABS 550MG 5 PA MO

Beta-lactam, Cephalosporins cefaclor er tb12 500mg 4 MO cefaclor caps 2 MO

cefaclor oral susp 125mg/5ml, 250mg/5ml, 375mg/5ml

2 MO

cefadroxil 2 MO CEFAZOLIN SODIUM INJ 1GM/50ML; 4%

3

cefazolin sodium inj 100gm, 1gm iv, 20gm, 300gm

4

cefazolin sodium inj 10gm, 1gm, 500mg

4 MO

CEFAZOLIN INJ 2GM/100ML; 4% 3


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cefdinir caps 2 MO cefdinir oral susp 3 MO cefepime inj 1gm, 2gm 4 MO cefixime caps 3 MO cefixime oral susp 4 MO cefotetan 4 cefoxitin sodium inj 10gm, 1gm, 2gm 4 cefpodoxime proxetil 4 MO cefprozil 3 MO CEFTAZIDIME/DEXTROSE 4 ceftazidime inj 6gm 4 ceftazidime inj 1gm, 2gm 4 MO ceftriaxone in iso-osmotic dextrose 4 ceftriaxone sodium inj 100gm, 1gm iv 4

ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg

4 MO

cefuroxime axetil tabs 3 MO cefuroxime sodium inj 1.5gm, 7.5gm 4 cefuroxime sodium inj 750mg 4 MO cephalexin 2 MO SUPRAX CAPS 3 MO SUPRAX CHEW 100MG 4 SUPRAX CHEW 200MG 4 MO SUPRAX ORAL SUSP 500MG/5ML 3 tazicef inj 1gm, 2gm, 6gm 4 TEFLARO 5

Beta-lactam, Other AZACTAM IN ISO-OSMOTIC

DEXTROSE INJ 1GM/50ML; 0, 2GM/50ML; 0

4

AZACTAM INJ 1GM, 2GM 4 aztreonam inj 1gm 4 MO aztreonam inj 2gm 5 MO ertapenem 4 MO imipenem/cilastatin 4 MO INVANZ 4 MO meropenem inj 500mg 4 meropenem inj 1gm 4 MO


17


Beta-lactam, Penicillins amoxicillin/clavulanate potassium 2 MO amoxicillin/clavulanate potassium er 4 MO amoxicillin chew 125mg, 250mg 1 MO amoxicillin caps, oral susp, tabs 1 MO ampicillin sodium inj 10gm, 125mg, 1gm iv, 250mg, 2gm iv

4

ampicillin sodium inj 1gm, 2gm, 500mg

4 MO

ampicillin-sulbactam 4 ampicillin caps 500mg 1 MO AUGMENTIN ES-600 4 MO

AUGMENTIN ORAL SUSP 125MG/5ML

4 MO

AUGMENTIN ORAL SUSP 250MG/5ML

5 MO

AUGMENTIN TABS 500MG; 125MG, 875MG; 125MG

4 MO

BICILLIN L-A INJ 1200000UNIT/2ML, 2400000UNIT/4ML, 600000UNIT/ML

4 MO

dicloxacillin caps 3 MO nafcillin sodium inj 10gm iv, 1gm,

2gm iv 4

nafcillin sodium inj 2gm 4 MO nafcillin sodium inj 10gm 5 oxacillin sodium inj 10gm, 1gm 4 oxacillin sodium inj 2gm 4 MO PENICILLIN G POTASSIUM IN ISO-OSMOTIC DEXTROSE

4

penicillin g potassium inj 20000000unit, 5000000unit

4 MO

penicillin g procaine 4 MO penicillin g sodium 4 penicillin v potassium 1 MO

piperacillin sodium/tazobactam sodium

4

piperacillin/tazobactam inj 12gm; 1.5gm, 36gm; 4.5gm

4

Macrolides AZITHROMYCIN PACK 3 MO


18


azithromycin oral susp, tabs 2 MO azithromycin inj 500mg 4 MO clarithromycin er 4 MO clarithromycin oral susp, tabs 3 MO DIFICID 5 MO E.E.S. 400 TABS 4 MO ERY-TAB 4

ERYTHROCIN LACTOBIONATE INJ 500MG

4

ERYTHROCIN STEARATE TABS 250MG

4 MO

erythromycin base 3 MO erythromycin dr 4 MO erythromycin ethylsuccinate tabs 3 MO erythromycin stearate tabs 250mg 3 MO erythromycin cpep 250mg 3 MO

Quinolones ciprofloxacin er 3 MO ciprofloxacin hcl tabs 100mg, 750mg 1 MO

ciprofloxacin hydrochloride tabs 250mg, 500mg

1 MO

ciprofloxacin i.v.-in d5w inj 200mg/100ml; 5%

4

ciprofloxacin i.v.-in d5w inj 400mg/200ml; 5%

4 MO

CIPROFLOXACIN OTIC (EAR) SOLN 3 MO ciprofloxacin oral susp 500mg/5ml 3 MO levofloxacin in d5w 4 levofloxacin inj 25mg/ml 4 levofloxacin oral soln 25mg/ml 3 MO

levofloxacin tabs 250mg, 500mg, 750mg

2 MO

moxifloxacin hydrochloride/sodium hydrochloride inj

4

moxifloxacin hydrochloride inj 400mg/250ml

4

moxifloxacin hydrochloride (generic Vigamox) ophthalmic soln 0.5%

3 MO

moxifloxacin hydrochloride tabs 400mg

4 MO


19


Sulfonamides sulfadiazine tabs 4 MO sulfamethoxazole/trimethoprim ds 1 MO sulfamethoxazole/trimethoprim tabs 1 MO

sulfamethoxazole/trimethoprim inj, susp

4 MO

Tetracyclines doxy 100 inj 4 MO

doxycycline hyclate dr tbec 100mg, 150mg, 200mg, 50mg, 75mg

4 MO

doxycycline hyclate caps 3 MO doxycycline hyclate inj 4 MO

doxycycline hyclate tabs 100mg, 150mg, 20mg, 75mg

3 MO

doxycycline monohydrate tabs 2 MO doxycycline monohydrate caps 4 MO doxycycline oral susp 3 MO minocycline hcl caps 75mg 2 MO minocycline hcl tabs 4 ST MO minocycline hydrochloride er 4 ST MO

minocycline hydrochloride caps 100mg, 50mg

2 MO

mondoxyne nl 4 morgidox 1x100mg caps 4 morgidox 1x50mg caps 4 morgidox 2x100mg caps 4 okebo caps 75mg 4 soloxide 4 tetracycline hydrochloride caps 4 MO

ANTICONVULSANTS Anticonvulsants, Other

APTIOM 5 MO BRIVIACT INJ 4 PA BRIVIACT ORAL SOLN, TABS 5 PA MO EPIDIOLEX 5 QL (600 ML per 30 days) PA LA FINTEPLA 5 QL (360 ML per 30 days) PA FYCOMPA SUSP 5 QL (720 ML per 30 days) PA MO FYCOMPA TABS 2MG 4 QL (60 EA per 30 days) PA MO FYCOMPA TABS 10MG, 12MG, 8MG 5 QL (30 EA per 30 days) PA MO


20


FYCOMPA TABS 4MG, 6MG 5 QL (60 EA per 30 days) PA MO levetiracetam er 4 MO

levetiracetam/sodium chloride inj 5mg/ml, 10mg/ml, 15mg/ml

4

levetiracetam oral soln, tabs 2 MO levetiracetam inj 4 roweepra 2 roweepra xr 4 SPRITAM 4 MO XCOPRI TABS 150MG 5

XCOPRI TABS 100MG, 200MG, 50MG

5 MO

XCORPI PAK 12.5MG-25MG 4 MO XCORPI TBPK 50MG, 100MG, 50-200MG, 150MG-200MG, 200MG

5 MO

Calcium Channel Modifying Agents CELONTIN CAPS 300MG 4 MO ethosuximide 4 MO

pregabalin caps 100mg, 150mg, 25mg, 50mg, 75mg


pregabalin caps 225mg, 300mg 3 QL (60 EA per 30 days) PA MO pregabalin caps 200mg 3 QL (90 EA per 30 days) PA MO pregabalin soln 3 QL (900 ML per 30 days) PA MO zonisamide 2 MO

Gamma-aminobutyric Acid (GABA) Augmenting Agents clobazam susp 5 PA MO clobazam tabs 10mg 4 PA MO clobazam tabs 20mg 5 PA MO clonazepam odt tbdp 1mg 3 QL (120 EA per 30 days) MO clonazepam odt tbdp 2mg 3 QL (300 EA per 30 days) MO

clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg


clonazepam tabs 1mg 2 QL (120 EA per 30 days) MO clonazepam tabs 2mg 2 QL (300 EA per 30 days) MO clonazepam tabs 0.5mg 2 QL (90 EA per 30 days) MO DIASTAT ACUDIAL 4 MO DIASTAT PEDIATRIC GEL 2.5MG 4 MO diazepam rectal gel 4 MO divalproex sodium dr 3 MO


21

Drug name Drug tier Requirements/Limits divalproex sodium er 4 MO divalproex sodium sprinkle caps 3 MO gabapentin caps 300mg 3 QL (360 EA per 30 days) MO gabapentin caps 100mg, 400mg 3 QL (90 EA per 30 days) MO gabapentin soln 3 QL (2160 ML per 30 days) MO gabapentin tabs 600mg 3 QL (180 EA per 30 days) MO gabapentin tabs 800mg 3 QL (90 EA per 30 days) MO GABITRIL TABS 12MG, 16MG 4 MO GABITRIL TABS 2MG, 4MG 5 MO NAYZILAM 4 MO ONFI SUSP 5 PA MO ONFI TABS 10MG, 20MG 5 PA MO phenobarbital sodium inj 4 PA phenobarbital elix 4 QL (1500 ML per 30 days) PA MO phenobarbital tabs 100mg, 15mg, 16.2mg, 30mg, 32.4mg, 60mg, 64.8mg, 97.2mg


primidone tabs 2 MO SABRIL TABS 5 QL (180 EA per 30 days) PA LA SYMPAZAN FILM 5MG 4 PA MO SYMPAZAN FILM 10MG, 20MG 5 PA MO tiagabine tabs 4 MO valproate sodium inj 100mg/ml 4 valproic acid caps, soln 2 MO VALTOCO 4 QL (10 EA per 30 days) vigabatrin pack 4 QL (180 EA per 30 days) PA vigabatrin tabs 5 QL (180 EA per 30 days) PA vigadrone 4 QL (180 EA per 30 days) PA

Glutamate Reducing Agents felbamate 4 MO lamotrigine er 4 MO lamotrigine odt 4 MO lamotrigine starter kit/blue 4 MO lamotrigine starter kit/green 4 MO lamotrigine starter kit/orange 4 MO lamotrigine chew, tabs 2 MO subvenite 2 subvenite starter kit/blue 4 subvenite starter kit/green 4


22

Drug name Drug tier Requirements/Limits subvenite starter kit/orange 4 topiramate er 4 MO topiramate sprinkle caps, tabs 2 MO

Sodium Channel Agents BANZEL 5 PA MO carbamazepine er 4 MO carbamazepine chew, susp, tabs 2 MO DILANTIN INFATABS 3 MO DILANTIN-125 4 MO DILANTIN CAPS 3 MO epitol 4 fosphenytoin sodium inj 100mg pe/2ml

4

fosphenytoin sodium inj 500mg pe/10ml

4 MO

oxcarbazepine tabs 3 MO oxcarbazepine susp 4 MO PEGANONE TABS 250MG 4 MO PHENYTEK 3 MO phenytoin sodium er caps 3 MO phenytoin sodium inj 4 phenytoin chew, susp 3 MO VIMPAT INJ 5 VIMPAT ORAL SOLN 5 MO VIMPAT TABS 50MG 4 MO VIMPAT TABS 100MG, 150MG, 200MG

5 MO

ANTIDEMENTIA AGENTS Cholinesterase Inhibitors

donepezil hcl tbdp 2 QL (30 EA per 30 days) MO donepezil hcl tabs 10mg 2 QL (60 EA per 30 days) MO donepezil hcl tabs 23mg 3 QL (30 EA per 30 days) MO donepezil hydrochloride tabs 5mg 2 QL (30 EA per 30 days) MO galantamine hydrobromide er 4 QL (30 EA per 30 days) MO galantamine hydrobromide soln 4 QL (200 ML per 30 days) MO galantamine hydrobromide tabs 4 QL (60 EA per 30 days) MO rivastigmine patch 4 QL (30 EA per 30 days) MO rivastigmine tartrate caps 4 QL (60 EA per 30 days) MO


23


N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hcl titration pak 3 QL (98 EA per 365 days) PA MO memantine hydrochloride er 4 PA MO memantine hydrochloride soln 3 QL (360 ML per 30 days) PA MO memantine hydrochloride tabs 3 QL (60 EA per 30 days) PA MO NAMZARIC 4 MO

ANTIDEPRESSANTS Antidepressants, Other

bupropion hcl tabs 100mg 3 QL (180 EA per 30 days) MO bupropion hydrochloride er (sr) tb12

100mg, 150mg, 200mg 3 QL (60 EA per 30 days) MO

bupropion hydrochloride er (xl) tb24 150mg, 300mg


bupropion hydrochloride tabs 75mg 3 QL (180 EA per 30 days) MO mirtazapine odt 3 QL (30 EA per 30 days) MO mirtazapine tabs 2 QL (30 EA per 30 days) MO TRINTELLIX TABS 5MG 4 QL (120 EA per 30 days) MO TRINTELLIX TABS 20MG 4 QL (30 EA per 30 days) MO TRINTELLIX TABS 10MG 4 QL (60 EA per 30 days) MO

Monoamine Oxidase Inhibitors EMSAM 5 QL (30 EA per 30 days) PA MO MARPLAN 4 QL (180 EA per 30 days) MO phenelzine sulfate 3 MO tranylcypromine sulfate 4 MO

SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor

citalopram hydrobromide soln 3 QL (600 ML per 30 days) MO citalopram hydrobromide tabs 10mg 1 QL (120 EA per 30 days) MO citalopram hydrobromide tabs 40mg 1 QL (30 EA per 30 days) MO citalopram hydrobromide tabs 20mg 1 QL (60 EA per 30 days) MO

DESVENLAFAXINE ER (GENERIC KHEDEZLA) TB24 100MG, 50MG


desvenlafaxine er (generic Pristiq) tb24 100mg, 25mg, 50mg


DRIZALMA SPRINKLE CSDR 20MG, 30MG, 60MG


DRIZALMA SPRINKLE CSDR 40MG 4 QL (90 EA per 30 days) PA MO duloxetine hcl cpep 40mg 3 QL (60 EA per 30 days) MO

duloxetine hydrochloride cpep 20mg, 60mg



24


duloxetine hydrochloride cpep 30mg 3 QL (90 EA per 30 days) MO escitalopram oxalate soln 3 QL (600 ML per 30 days) MO escitalopram oxalate tabs 20mg 3 QL (30 EA per 30 days) MO escitalopram oxalate tabs 10mg, 5mg 3 QL (45 EA per 30 days) MO FETZIMA TITRATION PACK 4 PA MO FETZIMA CP24 120MG, 80MG 4 QL (30 EA per 30 days) PA MO FETZIMA CP24 20MG, 40MG 4 QL (60 EA per 30 days) PA MO

fluoxetine (generic Sarafem) caps 10mg, 20mg

2 MO

fluoxetine dr 4 QL (4 EA per 28 days) MO fluoxetine hcl caps 20mg 2 QL (120 EA per 30 days) MO fluoxetine hydrochloride caps 10mg 2 QL (30 EA per 30 days) MO fluoxetine hydrochloride caps 40mg 2 QL (60 EA per 30 days) MO fluoxetine hydrochloride soln 2 MO

FLUOXETINE HYDROCHLORIDE TABS 60MG

3 MO

fluoxetine hydrochloride (generic Prozac) tabs 10mg, 20mg

2 MO

fluvoxamine maleate er 4 QL (60 EA per 30 days) MO fluvoxamine maleate tabs 3 MO maprotiline hcl 4 MO nefazodone hcl tabs 100mg, 150mg 4 MO

nefazodone hydrochloride tabs 200mg, 250mg, 50mg

4 MO

paroxetine hcl er tb24 37.5mg 4 QL (60 EA per 30 days) MO paroxetine hcl er tb24 12.5mg, 25mg 4 QL (90 EA per 30 days) MO paroxetine hcl tabs 30mg, 40mg 2 QL (60 EA per 30 days) MO

paroxetine hydrochloride tabs 10mg, 20mg


PAXIL SUSP 4 QL (900 ML per 30 days) MO sertraline hcl conc 3 QL (300 ML per 30 days) MO sertraline hcl tabs 25mg 1 QL (30 EA per 30 days) MO sertraline hcl tabs 50mg 1 QL (60 EA per 30 days) MO sertraline hydrochloride tabs 100mg 1 QL (60 EA per 30 days) MO trazodone hydrochloride 1 MO venlafaxine hcl 2 MO venlafaxine hcl er cp24 37.5mg 2 QL (30 EA per 30 days) MO venlafaxine hcl er cp24 150mg 2 QL (60 EA per 30 days) MO venlafaxine hcl er tb24 37.5mg 2 QL (30 EA per 30 days) MO


25


venlafaxine hydrochloride er cp24 75mg


venlafaxine hydrochloride er tb24 225mg, 75mg


venlafaxine hydrochloride er tb24 150mg


VIIBRYD STARTER PACK 4 MO VIIBRYD TABS 4 QL (30 EA per 30 days) MO

Tricyclics amitriptyline hcl tabs 100mg, 150mg,

25mg, 75mg 3 PA MO

amitriptyline hydrochloride tabs 10mg, 50mg

3 PA MO

amoxapine 3 MO chlordiazepoxide/amitriptyline 4 PA MO clomipramine hcl caps 4 PA MO desipramine hcl tabs 4 MO imipramine hcl tabs 25mg, 50mg 3 PA MO imipramine hydrochloride tabs 10mg 3 PA MO imipramine pamoate 4 PA MO nortriptyline hcl caps 25mg, 75mg 3 MO nortriptyline hcl soln 3 MO

nortriptyline hydrochloride caps 10mg, 50mg

3 MO

perphenazine/amitriptyline 4 PA MO protriptyline hcl 4 MO trimipramine maleate caps 4 PA MO


ANTIEMETICS Antiemetics, Other

dimenhydrinate inj 4 meclizine hcl tabs 2 MO phenadoz supp 25mg 4 PA phenadoz supp 12.5mg 4 PA MO promethazine hcl supp 12.5mg, 25mg, 50mg

4 PA MO

promethegan supp 12.5mg, 25mg 4 PA promethegan supp 50mg 4 PA MO scopolamine patch 4 QL (10 EA per 30 days) PA MO TRANSDERM-SCOP 4 QL (10 EA per 30 days) PA MO trimethobenzamide hcl caps 300mg 4 PA MO

26


Emetogenic Therapy Adjuncts aprepitant 4 B/D MO dronabinol 4 QL (60 EA per 30 days) PA MO EMEND ORAL SUSP 4 B/D MO granisetron hcl tabs 3 QL (60 EA per 30 days) B/D MO ondansetron hcl oral soln 3 QL (900 ML per 30 days) B/D MO ondansetron hcl inj 40mg/20ml 4 MO ondansetron hcl tabs 24mg 2 B/D

ondansetron hydrochloride tabs 4mg, 8mg

2 B/D MO

ondansetron hydrochloride inj 4mg/2ml

4 MO

ondansetron odt 3 B/D MO SANCUSO 5 QL (4 EA per 28 days) MO


ANTIFUNGALS Antifungals

ABELCET 4 B/D AMBISOME 5 B/D amphotericin b inj 4 B/D MO caspofungin acetate inj 70mg 4 caspofungin acetate inj 50mg 5 ciclopirox olamine crea 3 QL (90 GM per 30 days) MO ciclopirox gel 3 QL (100 GM per 30 days) MO ciclopirox sham 3 QL (120 ML per 30 days) MO ciclopirox susp 3 QL (60 ML per 30 days) MO clotrimazole/betamethasone dipropionate crea

4 QL (45 GM per 30 days) MO

clotrimazole troc 3 MO clotrimazole topical soln 3 QL (30 ML per 30 days) MO clotrimazole crea 3 QL (45 GM per 30 days) MO econazole nitrate crea 4 QL (85 GM per 30 days) MO ERTACZO 5 QL (60 GM per 30 days) MO fluconazole in nacl inj 200mg/100ml; 0.9%

4

fluconazole in sodium chloride inj 400mg/200ml; 0.9%

4

fluconazole tabs 2 MO fluconazole oral susp 3 MO flucytosine caps 5 MO

27


Drug name Drug tier Requirements/Limits griseofulvin microsize 4 MO griseofulvin ultramicrosize tabs 125mg, 250mg

4 MO

itraconazole caps 4 PA MO ketoconazole tabs 2 PA MO ketoconazole sham 2 QL (120 ML per 30 days) MO ketoconazole crea 3 QL (60 GM per 30 days) MO ketoconazole foam 4 QL (100 GM per 30 days) MO micafungin inj 50mg 4 micafungin inj 100mg 5 miconazole 3 supp 4 MO MYCAMINE INJ 50MG 4 MO MYCAMINE INJ 100MG 5 naftifine hcl 1% cream 4 QL (90 GM per 30 days) MO naftifine hydrochloride 2% cream 4 QL (60 GM per 30 days) MO NOXAFIL SUSP 5 QL (630 ML per 30 days) MO NOXAFIL TBEC 5 QL (93 EA per 30 days) MO nyamyc 3 QL (60 GM per 30 days) nystatin crea 2 QL (30 GM per 30 days) MO nystatin powd 3 QL (60 GM per 30 days) MO nystatin oral susp, tabs 4 MO nystatin oint 4 QL (30 GM per 30 days) MO nystop 3 QL (60 GM per 30 days) MO oxiconazole nitrate 4 QL (90 GM per 30 days) MO posaconazole dr 5 QL (93 EA per 30 days) MO terbinafine hcl tabs 2 QL (90 EA per 365 days) MO terconazole crea 3 MO terconazole supp 4 MO voriconazole inj 4 voriconazole oral susp, tabs 4 MO

ANTIGOUT AGENTS Antigout Agents

allopurinol tabs 1 MO colchicine caps 3 QL (60 EA per 30 days) MO colchicine tabs 0.6mg 3 QL (120 EA per 30 days) MO COLCRYS 3 QL (120 EA per 30 days) MO febuxostat 3 ST MO MITIGARE 3 QL (60 EA per 30 days) MO probenecid/colchicine 3 MO

28


Drug name Drug tier Requirements/Limits probenecid tabs 3 MO

ANTIMIGRAINE AGENTS Ergot Alkaloids

dihydroergotamine mesylate inj 4 PA MO dihydroergotamine mesylate nasal soln

4 QL (8 ML per 28 days) PA MO

ergotamine tartrate/caffeine 3 MO Prophylactic

AIMOVIG INJ 140MG/ML 3 QL (1 ML per 30 days) PA AIMOVIG INJ 70MG/ML 3 QL (2 ML per 30 days) PA EMGALITY INJ 120MG/ML 3 QL (2 ML per 30 days) PA EMGALITY INJ 100MG/ML 3 QL (3 ML per 30 days) PA

Serotonin (5-HT) 1b/1d Receptor Agonists almotriptan malate 4 QL (8 EA per 30 days) MO eletriptan hydrobromide 3 QL (12 EA per 30 days) MO frovatriptan succinate 4 QL (12 EA per 30 days) MO naratriptan hcl 3 QL (9 EA per 30 days) MO rizatriptan benzoate odt 3 QL (12 EA per 30 days) MO rizatriptan benzoate tabs 3 QL (12 EA per 30 days) MO sumatriptan succinate refill 4 QL (4 ML per 30 days) MO sumatriptan succinate tabs 2 QL (9 EA per 30 days) MO sumatriptan succinate prefilled syringe 6mg/0.5ml

4 QL (4 ML per 30 days)

sumatriptan succinate inj 4mg/0.5ml, 6mg/0.5ml


sumatriptan/naproxen sodium 4 QL (9 EA per 30 days) MO sumatriptan soln 2 QL (12 EA per 30 days) MO zolmitriptan odt 4 QL (6 EA per 30 days) MO zolmitriptan tabs 4 QL (6 EA per 30 days) MO

ANTIMYASTHENIC AGENTS Parasympathomimetics

GUANIDINE HCL 4 pyridostigmine bromide er 3 MO pyridostigmine bromide tabs 3 MO

ANTIMYCOBACTERIALS Antimycobacterials, Other

dapsone tabs 100mg, 25mg 3 MO rifabutin 4 MO

29


Drug name Drug tier Requirements/Limits Antituberculars

cycloserine 5 MO ethambutol hcl tabs 100mg, 400mg 4 MO isoniazid tabs 1 MO isoniazid syrp 2 MO isoniazid inj 4 PASER 4 MO PRETOMANID 4 QL (30 EA per 30 days) PA PRIFTIN 4 MO pyrazinamide tabs 4 MO rifampin caps 3 MO rifampin inj 4 RIFATER 4 MO SIRTURO TABS 20MG 5 PA SIRTURO TABS 100MG 5 PA LA TRECATOR 4 MO

ANTINEOPLASTICS Alkylating Agents

BENDEKA 5 busulfan 5 cyclophosphamide caps 3 B/D MO CYCLOPHOSPHAMIDE INJ 1GM/5ML, 500MG/2.5ML

4

cyclophosphamide inj 1gm, 2gm, 500mg

4

GLEOSTINE CAPS 10MG 4 MO GLEOSTINE CAPS 100MG, 40MG 5 MO KISQALI FEMARA 200MG-2.5MG CO-PACK

5 PA

KISQALI FEMARA 400MG-2.5MG CO-PACK

5 PA

KISQALI FEMARA 600MG-2.5MG CO-PACK

5 PA

LEUKERAN 5 MO MATULANE 5 LA melphalan hydrochloride inj 5 melphalan tabs 4 B/D MO thiotepa inj 15mg 5 VALCHLOR 5 QL (60 GM per 30 days) PA LA

MO

30


Drug name Drug tier Requirements/Limits ZEPZELCA 5 PA

Antiandrogens abiraterone acetate 5 PA bicalutamide 3 MO ERLEADA 5 PA LA flutamide 4 MO nilutamide 5 MO NUBEQA 5 QL (120 EA per 30 days) PA XTANDI 5 PA LA ZYTIGA 5 PA LA

Antiangiogenic Agents POMALYST CAPS 1MG, 2MG 5 QL (21 EA per 21 days) PA LA POMALYST CAPS 3MG, 4MG 5 QL (21 EA per 28 days) PA LA REVLIMID 5 QL (28 EA per 28 days) PA LA THALOMID CAPS 100MG, 50MG 5 QL (28 EA per 28 days) PA THALOMID CAPS 150MG, 200MG 5 QL (56 EA per 28 days) PA

Antiestrogens/Modifiers EMCYT 4 MO FARESTON 5 PA MO SOLTAMOX 5 MO tamoxifen citrate tabs 2 MO toremifene citrate 4 PA MO

Antimetabolites clofarabine 5 DROXIA 3 MO fluorouracil inj 1gm/20ml 3 B/D hydroxyurea caps 2 MO mercaptopurine tabs 4 MO PURIXAN 5 TABLOID 4 MO

Antineoplastics, Other ABRAXANE 5 adrucil 3 B/D ALIMTA 5 arsenic trioxide 5 AVASTIN 5 PA LA bleomycin sulfate 4 B/D BORTEZOMIB 5 PA BRAFTOVI 5 PA LA MO

31


BRUKINSA 5 QL (120 EA per 30 days) PA MO carboplatin 3 carmustine 5

cisplatin inj 100mg/100ml, 200mg/200ml, 50mg/50ml

3

cladribine 4 B/D COPIKTRA 5 PA LA MO cytarabine aqueous 4 B/D dacarbazine 4 dactinomycin 5

DAUNORUBICIN HYDROCHLORIDE INJ 50MG/10ML

4

daunorubicin hydrochloride inj 20mg/4ml

4

decitabine 4 dexrazoxane 4 DOCETAXEL INJ 160MG/16ML 4 B/D

DOCETAXEL INJ 20MG/2ML, 80MG/8ML

5 B/D

docetaxel inj 20mg/ml, 80mg/4ml 4 B/D docetaxel inj 160mg/8ml,

200mg/10ml 5 B/D

doxorubicin hcl liposome 2mg/ml pf 4 doxorubicin hydrochloride liposomal

20mg/10ml, 50mg/25ml 4

epirubicin hcl inj 200mg/100ml, 50mg/25ml

4

FASLODEX 5 fludarabine phosphate 4

fluorouracil inj 2.5gm/50ml, 500mg/10ml, 5gm/100ml

3 B/D

fulvestrant 5 gemcitabine hcl inj 1gm, 200mg, 2gm 4

gemcitabine hydrochloride inj 100mg/ml

4

gemcitabine inj 38mg/ml 4 HERCEPTIN INJ 440MG 5 PA idarubicin hcl 4 IFEX INJ 3GM 4 ifosfamide 4


32


IMLYGIC 5 PA INQOVI 5 QL (5 EA per 28 days) PA INTRON A INJ 10MU 4 INTRON A INJ 10MU/ML, 18MU 5 irinotecan 4

irinotecan hydrochloride inj 300mg/15ml

4

KADCYLA 5 KHAPZORY 5 PA KISQALI 5 PA leucovorin calcium tabs 3 MO

leucovorin calcium inj 100mg/10ml, 100mg, 200mg, 350mg, 500mg/50ml,

500mg, 50mg

4

levoleucovorin calcium inj 175mg/17.5ml, 250mg/25ml

5

LEVOLEUCOVORIN INJ 175MG 5 levoleucovorin inj 50mg 5 LIBTAYO 5 PA LONSURF 5 PA LUMOXITI 5 PA LYNPARZA TABS 5 PA LA MEKTOVI 5 PA LA mesna 4 MESNEX TABS 5 MO mitomycin inj 20mg, 5mg 4 mitomycin inj 40mg 5 mitoxantrone hcl inj 2mg/ml 3 mutamycin inj 20mg, 5mg 4 mutamycin inj 40mg 5 NERLYNX 5 PA LA NINLARO 5 PA NIPENT 5

oxaliplatin inj 100mg/20ml, 100mg, 50mg/10ml, 50mg

4

paclitaxel inj 100mg/16.7ml, 150mg/25ml, 300mg/50ml, 30mg/5ml

4

PADCEV 5 PA paraplatin inj 450mg/45ml,

50mg/5ml 3


33


romidepsin 5 RUBRACA 5 PA LA RYDAPT 5 PA SYNRIBO 5 PA TALZENNA 5 PA LA TAXOTERE INJ 80MG/4ML 5 B/D TAZVERIK 5 QL (240 EA per 30 days) PA MO TRISENOX INJ 12MG/6ML 5 VELCADE 5 PA VERZENIO 5 PA LA vinblastine sulfate inj 1mg/ml 4 B/D vincasar pfs 4 B/D vincristine sulfate 4 B/D vinorelbine tartrate 4 VIZIMPRO 5 PA LA XPOVIO 100 MG ONCE WEEKLY 5 QL (20 EA per 28 days) PA MO XPOVIO 40 MG ONCE WEEKLY 5 QL (8 EA per 28 days) PA XPOVIO 40 MG TWICE WEEKLY 5 QL (16 EA per 28 days) PA XPOVIO 60 MG ONCE WEEKLY 5 QL (12 EA per 28 days) PA MO XPOVIO 60 MG TWICE WEEKLY 5 QL (24 EA per 28 days) PA XPOVIO 80 MG ONCE WEEKLY 5 QL (32 EA per 28 days) PA MO XPOVIO 80 MG TWICE WEEKLY 5 QL (32 EA per 28 days) PA MO YERVOY 5 PA ZEJULA 5 PA LA MO ZOLINZA 5 PA

Aromatase Inhibitors, 3rd Generation anastrozole tabs 2 MO exemestane 4 MO letrozole 2 MO

Enzyme Inhibitors etoposide inj 100mg/5ml, 1gm/50ml,

500mg/25ml 3

toposar inj 100mg/5ml, 1gm/50ml, 500mg/25ml

3

TOPOTECAN HCL INJ 4MG/4ML 5 topotecan hcl inj 4mg 5

Molecular Target Inhibitors AFINITOR 5 QL (30 EA per 30 days) PA AFINITOR DISPERZ TBSO 2MG 5 QL (150 EA per 30 days) PA


34

Drug name Drug tier Requirements/Limits AFINITOR DISPERZ TBSO 5MG 5 QL (60 EA per 30 days) PA AFINITOR DISPERZ TBSO 3MG 5 QL (90 EA per 30 days) PA ALECENSA 5 PA LA ALUNBRIG 5 PA LA AYVAKIT 5 QL (30 EA per 30 days) PA MO BALVERSA TABS 5MG 5 QL (28 EA per 28 days) PA MO BALVERSA TABS 4MG 5 QL (56 EA per 28 days) PA MO BALVERSA TABS 3MG 5 QL (84 EA per 28 days) PA MO BELEODAQ 5 PA BOSULIF 5 PA CABOMETYX 5 QL (30 EA per 30 days) PA LA CALQUENCE 5 PA LA MO CAPRELSA 5 PA LA MO COMETRIQ 5 PA LA COTELLIC 5 PA LA DAURISMO 5 PA LA ERIVEDGE 5 PA LA erlotinib hydrochloride tabs 100mg, 150mg

5 QL (30 EA per 30 days) PA

erlotinib hydrochloride tabs 25mg 5 QL (90 EA per 30 days) PA everolimus tabs 2.5mg, 5mg, 7.5mg 5 QL (30 EA per 30 days) PA FARYDAK 5 PA LA GILOTRIF 5 PA LA MO IBRANCE TABS 5 QL (21 EA per 28 days) PA IBRANCE CAPS 5 QL (21 EA per 28 days) PA LA ICLUSIG 5 PA LA MO IDHIFA 5 QL (30 EA per 30 days) PA LA imatinib mesylate tabs 400mg 5 QL (60 EA per 30 days) PA imatinib mesylate tabs 100mg 5 QL (90 EA per 30 days) PA IMBRUVICA 5 PA LA MO INLYTA TABS 5MG 5 QL (120 EA per 30 days) PA LA INLYTA TABS 1MG 5 QL (180 EA per 30 days) PA LA INREBIC 5 QL (120 EA per 30 days) PA IRESSA 5 PA LA JAKAFI 5 QL (60 EA per 30 days) PA LA LENVIMA 10 MG DAILY DOSE 5 PA LA LENVIMA 12MG DAILY DOSE 5 PA LA LENVIMA 14 MG DAILY DOSE 5 PA LA LENVIMA 18 MG DAILY DOSE 5 PA LA


35

Drug name Drug tier Requirements/Limits LENVIMA 20 MG DAILY DOSE 5 PA LA LENVIMA 24 MG DAILY DOSE 5 PA LA LENVIMA 4 MG DAILY DOSE 5 PA LA LENVIMA 8 MG DAILY DOSE 5 PA LA LORBRENA 5 PA LA MEKINIST 5 PA LA NEXAVAR 5 PA LA ODOMZO 5 PA LA PEMAZYRE 5 QL (14 EA per 21 days) PA MO PIQRAY 200MG DAILY DOSE 5 QL (28 EA per 28 days) PA PIQRAY 250MG DAILY DOSE 5 QL (56 EA per 28 days) PA PIQRAY 300MG DAILY DOSE 5 QL (56 EA per 28 days) PA QINLOCK 5 QL (90 EA per 30 days) PA MO RETEVMO CAPS 80MG 5 QL (120 EA per 30 days) PA RETEVMO CAPS 40MG 5 QL (180 EA per 30 days) PA ROZLYTREK CAPS 100MG 5 QL (150 EA per 30 days) PA ROZLYTREK CAPS 200MG 5 QL (90 EA per 30 days) PA SPRYCEL 5 PA STIVARGA 5 PA LA SUTENT 5 QL (30 EA per 30 days) PA TABRECTA 5 QL (112 EA per 28 days) PA TAFINLAR 5 PA LA TAGRISSO 5 QL (30 EA per 30 days) PA LA TARCEVA TABS 100MG, 150MG 5 QL (30 EA per 30 days) PA LA TARCEVA TABS 25MG 5 QL (90 EA per 30 days) PA LA TASIGNA 5 PA temsirolimus 5 TIBSOVO 5 PA LA TUKYSA TABS 150MG 5 QL (120 EA per 30 days) PA MO TUKYSA TABS 50MG 5 QL (240 EA per 30 days) PA MO TURALIO 5 QL (120 EA per 30 days) PA MO TYKERB 5 PA LA VENCLEXTA STARTING PACK 5 PA LA MO VENCLEXTA TABS 10MG 4 PA LA MO VENCLEXTA TABS 100MG, 50MG 5 PA LA MO VITRAKVI 5 PA LA VOTRIENT 5 PA LA XALKORI 5 PA LA XOSPATA 5 PA LA MO


36


ZELBORAF 5 PA LA ZYDELIG 5 PA LA ZYKADIA TABS 5 PA ZYKADIA CAPS 5 PA LA

Monoclonal Antibody/Antibody-Drug Conjugate BLENREP 5 PA ENHERTU 5 PA HERCEPTIN HYLECTA 5 PA HERCEPTIN INJ 150MG 5 PA KEYTRUDA INJ 100MG/4ML 5 PA MONJUVI 5 PA MYLOTARG 5 PA LA PHESGO 5 PA POLIVY INJ 140MG 5 PA POTELIGEO 5 PA RITUXAN 5 PA LA RITUXAN HYCELA 5 PA LA SARCLISA 5 PA TECENTRIQ INJ 840MG/14ML 5 PA TECENTRIQ INJ 1200MG/20ML 5 PA LA TRODELVY 5 PA

Retinoids bexarotene 5 PA PANRETIN 5 QL (60 GM per 30 days) TARGRETIN GEL 5 QL (60 GM per 30 days) PA tretinoin caps 10mg 5 MO

Treatment Adjuncts ELITEK 5

ANTIPARASITICS Anthelmintics

albendazole tabs 5 MO ALBENZA 5 MO BILTRICIDE 3 MO EMVERM 5 QL (12 EA per 365 days) MO ivermectin tabs 3 MO praziquantel tabs 3 MO

Antiprotozoals ALINIA 5 MO atovaquone 4 PA MO


37


atovaquone/proguanil hcl 4 MO chloroquine phosphate tabs 2 MO COARTEM 4 MO hydroxychloroquine sulfate tabs 3 MO mefloquine hcl 3 MO NEBUPENT 4 B/D MO PENTAM 300 4 MO pentamidine isethionate inj 4 pentamidine isethionate inhalation solr

4 B/D

primaquine phosphate tabs 3 quinine sulfate caps 324mg 4 PA MO

Pediculicides/Scabicides malathion 3 MO permethrin crea 4 MO

ANTIPARKINSON AGENTS Anticholinergics

benztropine mesylate inj, tabs 2 PA MO trihexyphenidyl hcl soln 2 PA MO trihexyphenidyl hydrochloride tabs 2 PA MO

Antiparkinson Agents, Other amantadine hcl tabs 3 MO amantadine hcl caps, syrp 4 MO entacapone 4 MO

Dopamine Agonists APOKYN INJ 30MG/3ML 5 QL (60 ML per 30 days) PA LA bromocriptine mesylate caps, tabs 4 MO NEUPRO 4 MO pramipexole dihydrochloride er 4 QL (30 EA per 30 days) MO pramipexole dihydrochloride immediate release tabs

2 MO

ropinirole er tb24 6mg 4 QL (120 EA per 30 days) MO ropinirole er tb24 4mg 4 QL (150 EA per 30 days) MO ropinirole er tb24 2mg 4 QL (30 EA per 30 days) MO ropinirole er tb24 12mg 4 QL (60 EA per 30 days) MO ropinirole er tb24 8mg 4 QL (90 EA per 30 days) MO ropinirole hcl immediate release tabs 0.5mg, 1mg, 2mg, 4mg, 5mg

2 MO


38


ropinirole hydrochloride immediate release tabs 0.25mg, 3mg

2 MO

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors carbidopa/levodopa 2 MO carbidopa/levodopa er 4 MO carbidopa/levodopa odt 3 MO carbidopa/levodopa/entacapone 4 MO carbidopa tabs 5 MO STALEVO 100 5 ST MO STALEVO 125 5 ST MO STALEVO 150 5 ST MO STALEVO 200 5 ST MO STALEVO 50 4 ST MO STALEVO 75 5 ST MO

Monoamine Oxidase B (MAO-B) Inhibitors rasagiline mesylate tabs 3 MO selegiline hcl caps, tabs 2 MO

ANTIPSYCHOTICS 1st Generation/Typical

chlorpromazine hcl tabs 4 MO chlorpromazine hcl inj 50mg/2ml 4 chlorpromazine hcl inj 25mg/ml 4 MO compro 2 MO fluphenazine decanoate inj 4 MO fluphenazine hcl conc, tabs 2 MO fluphenazine hcl inj 4 MO fluphenazine hydrochloride elix 2 MO haloperidol decanoate inj 4 MO haloperidol lactate inj 4 MO haloperidol conc, tabs 3 MO

loxapine succinate caps 25mg, 50mg, 5mg

3 MO

loxapine caps 10mg 3 MO molindone hydrochloride 3 perphenazine tabs 4 MO pimozide 4 MO

prochlorperazine edisylate inj 50mg/10ml

4


39


prochlorperazine edisylate inj 10mg/2ml

4 MO

prochlorperazine maleate tabs 2 MO prochlorperazine supp 25mg 2 MO

thioridazine hcl tabs 100mg, 10mg, 25mg, 50mg

3 PA MO

thiothixene caps 10mg, 1mg, 2mg, 5mg

4 MO

trifluoperazine hcl tabs 4 MO 2nd Generation/Atypical

ABILIFY MAINTENA 5 QL (1 EA per 28 days) MO aripiprazole odt 5 QL (60 EA per 30 days) MO aripiprazole tabs 4 QL (30 EA per 30 days) MO aripiprazole soln 4 QL (900 ML per 30 days) MO ARISTADA INITIO 5 ARISTADA INJ 441MG/1.6ML 5 QL (1.6 ML per 28 days) ARISTADA INJ 662MG/2.4ML 5 QL (2.4 ML per 28 days) ARISTADA INJ 882MG/3.2ML 5 QL (3.2 ML per 28 days) ARISTADA INJ 1064MG/3.9ML 5 QL (3.9 ML per 56 days) CAPLYTA 5 QL (30 EA per 30 days) PA MO FANAPT 4 QL (60 EA per 30 days) PA MO FANAPT TITRATION PACK 4 PA MO GEODON INJ 4 QL (6 EA per 3 days) MO

INVEGA SUSTENNA INJ 39MG/0.25ML

4 QL (0.25 ML per 28 days) MO

INVEGA SUSTENNA INJ 78MG/0.5ML 5 QL (0.5 ML per 28 days) MO INVEGA SUSTENNA INJ

117MG/0.75ML 5 QL (0.75 ML per 28 days) MO

INVEGA SUSTENNA INJ 156MG/ML 5 QL (1 ML per 28 days) MO INVEGA SUSTENNA INJ

234MG/1.5ML 5 QL (1.5 ML per 28 days) MO

INVEGA TRINZA INJ 273MG/0.875ML 5 QL (0.88 ML per 90 days) INVEGA TRINZA INJ 410MG/1.315ML 5 QL (1.32 ML per 90 days) INVEGA TRINZA INJ 546MG/1.75ML 5 QL (1.75 ML per 90 days) INVEGA TRINZA INJ 819MG/2.625ML 5 QL (2.63 ML per 90 days)

LATUDA TABS 120MG, 20MG, 40MG, 60MG


LATUDA TABS 80MG 4 QL (60 EA per 30 days) MO NUPLAZID 5 QL (30 EA per 30 days) PA LA olanzapine odt 4 QL (30 EA per 30 days) MO


40


olanzapine inj 4 MO olanzapine tabs 10mg, 15mg, 20mg,

5mg, 7.5mg 3 QL (30 EA per 30 days) MO

olanzapine tabs 2.5mg 3 QL (60 EA per 30 days) MO paliperidone er tb24 1.5mg, 3mg 4 QL (30 EA per 30 days) MO paliperidone er tb24 6mg 4 QL (60 EA per 30 days) MO paliperidone er tb24 9mg 5 QL (30 EA per 30 days) MO PERSERIS 5 QL (1 EA per 30 days) quetiapine fumarate er tb24 50mg 4 QL (180 EA per 30 days) MO

quetiapine fumarate er tb24 150mg, 200mg


quetiapine fumarate er tb24 300mg, 400mg


quetiapine fumarate tabs 200mg 3 QL (120 EA per 30 days) MO quetiapine fumarate tabs 25mg 3 QL (180 EA per 30 days) MO

quetiapine fumarate tabs 300mg, 400mg


quetiapine fumarate tabs 100mg, 50mg


REXULTI TABS 3MG, 4MG 5 QL (30 EA per 30 days) MO REXULTI TABS 0.25MG, 0.5MG,

1MG, 2MG 5 QL (60 EA per 30 days) MO

RISPERDAL CONSTA INJ 12.5MG, 25MG


RISPERDAL CONSTA INJ 37.5MG, 50MG


risperidone odt tbdp 4mg 4 QL (120 EA per 30 days) MO risperidone odt tbdp 1mg, 2mg 4 QL (60 EA per 30 days) MO

risperidone odt tbdp 0.25mg, 0.5mg, 3mg


risperidone soln 2 MO risperidone tabs 4mg 2 QL (120 EA per 30 days) MO risperidone tabs 1mg, 2mg 2 QL (60 EA per 30 days) MO risperidone tabs 0.25mg, 0.5mg, 3mg 2 QL (90 EA per 30 days) MO SAPHRIS 4 QL (60 EA per 30 days) MO SECUADO 5 QL (30 EA per 30 days) PA VRAYLAR CAP THERAPY PACK 4 PA MO VRAYLAR CAPS 3MG, 4.5MG, 6MG 5 QL (30 EA per 30 days) PA MO VRAYLAR CAPS 1.5MG 5 QL (60 EA per 30 days) PA MO ziprasidone hcl 3 QL (60 EA per 30 days) MO


41


ziprasidone mesylate 4 QL (6 EA per 3 days) ZYPREXA RELPREVV INJ 210MG 4 QL (2 EA per 28 days) PA ZYPREXA RELPREVV INJ 405MG 5 QL (1 EA per 28 days) PA ZYPREXA RELPREVV INJ 300MG 5 QL (2 EA per 28 days) PA

Treatment-Resistant clozapine odt tbdp 12.5mg, 25mg 4 PA clozapine odt tbdp 200mg 4 QL (135 EA per 30 days) PA clozapine odt tbdp 150mg 4 QL (180 EA per 30 days) PA clozapine odt tbdp 100mg 4 QL (270 EA per 30 days) PA

clozapine tabs 100mg, 200mg, 25mg, 50mg

3

VERSACLOZ 5 QL (600 ML per 30 days) PA


ANTISPASTICITY AGENTS Antispasticity Agents

baclofen tabs 3 MO dantrolene sodium caps 4 MO tizanidine hcl caps 2 MO tizanidine hcl tabs 2mg 2 MO tizanidine hydrochloride tabs 4mg 2 MO

ANTIVIRALS Anti-cytomegalovirus (CMV) Agents

ganciclovir inj 500mg/10ml, 500mg 3 B/D PREVYMIS TABS 5 QL (28 EA per 28 days) MO valganciclovir oral soln 5 MO valganciclovir tabs 5 MO

Anti-hepatitis B (HBV) Agents adefovir dipivoxil 4 QL (30 EA per 30 days) MO BARACLUDE SOLN 4 MO entecavir 4 QL (30 EA per 30 days) MO EPIVIR HBV SOLN 4 MO lamivudine tabs 100mg 3 MO VEMLIDY 5 MO

Anti-hepatitis C (HCV) Agents, Direct Acting Agents EPCLUSA 5 PA HARVONI 5 PA MAVYRET 5 PA VOSEVI 5 PA

42


Anti-hepatitis C (HCV) Agents, Other INTRON A INJ 50MU, 6000000UNIT/ ML

5

PEGASYS 5 PA PEGASYS PROCLICK INJ

180MCG/0.5ML 5 PA

REBETOL SOLN 5 RIBASPHERE RIBAPAK TBPK 1000

DOSE PAK, 1200 DOSE PAK 5

ribasphere caps 3 RIBASPHERE TABS 600MG 5 ribasphere tabs 200mg 3 ribavirin caps 200mg 3 ribavirin tabs 200mg 3 SYLATRON 5 PA

Anti-HIV Agents, Integrase Inhibitors (INSTI) ATRIPLA 5 MO BIKTARVY 5 MO GENVOYA 5 MO ISENTRESS PACK 3 MO ISENTRESS TABS 5 MO ISENTRESS CHEW 25MG 3 MO ISENTRESS CHEW 100MG 5 MO TIVICAY PD 4 TIVICAY TABS 10MG 3 MO TIVICAY TABS 25MG, 50MG 5 MO

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) COMPLERA 5 MO EDURANT 5 MO efavirenz caps 50mg 3 MO efavirenz caps 200mg 4 MO efavirenz tabs 5 MO INTELENCE TABS 25MG 4 INTELENCE TABS 100MG, 200MG 5 MO nevirapine er tb24 100mg 3 nevirapine er tb24 400mg 3 MO nevirapine tabs 3 MO nevirapine susp 4 ODEFSEY 5 MO


43


RESCRIPTOR TABS 200MG 4 MO STRIBILD 5 MO SUSTIVA TABS 5 MO SUSTIVA CAPS 50MG 4 MO SUSTIVA CAPS 200MG 5 MO VIRAMUNE SUSP 4 MO

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) abacavir 3 MO abacavir sulfate/lamivudine 4 MO abacavir sulfate/ lamivudine/zidovudine

5 MO

CIMDUO 5 MO DESCOVY 5 MO

didanosine cpdr 200mg, 250mg, 400mg

4 MO

DOVATO 5 MO efavirenz/lamivudine/tenofovir disoproxil fumarate

5

emtricitabine 3 EMTRIVA 3 MO EPZICOM 5 MO JULUCA 5 MO lamivudine/zidovudine 4 MO lamivudine soln 10mg/ml 4 MO lamivudine tabs 150mg, 300mg 4 MO stavudine caps 3 MO SYMFI 5 MO SYMFI LO 5 MO TEMIXYS 5 MO tenofovir tabs 4 MO TRIUMEQ 5 MO TRUVADA 5 QL (30 EA per 30 days) MO VIDEX EC CPDR 125MG 4 MO VIDEX PEDIATRIC 4 MO VIREAD POWD 5 MO

VIREAD TABS 150MG, 200MG, 250MG

5 MO

zidovudine 3 MO


44


Anti-HIV Agents, Other DELSTRIGO 5 MO FUZEON 5 ISENTRESS HD 5 MO PIFELTRO 5 MO RUKOBIA 5 SELZENTRY SOLN 5 SELZENTRY TABS 25MG 4 SELZENTRY TABS 75MG 5 SELZENTRY TABS 150MG, 300MG 5 MO TROGARZO 5 LA TYBOST 4 MO

Anti-HIV Agents, Protease Inhibitors APTIVUS SOLN 5 APTIVUS CAPS 5 MO atazanavir sulfate caps 150mg 4 MO

atazanavir sulfate caps 200mg, 300mg

5 MO

CRIXIVAN CAPS 200MG, 400MG 4 MO EVOTAZ 5 MO fosamprenavir calcium 5 MO INVIRASE TABS 5 MO KALETRA TABS 100MG; 25MG 4 MO KALETRA TABS 200MG; 50MG 5 MO LEXIVA SUSP 4 MO lopinavir/ritonavir 4 MO NORVIR TABS 3 MO NORVIR PACK, SOLN 4 MO PREZCOBIX 5 MO PREZISTA SUSP 5 QL (400 ML per 30 days) MO PREZISTA TABS 75MG 4 QL (480 EA per 30 days) MO PREZISTA TABS 150MG 5 QL (240 EA per 30 days) MO PREZISTA TABS 800MG 5 QL (30 EA per 30 days) MO PREZISTA TABS 600MG 5 QL (60 EA per 30 days) MO REYATAZ 5 MO ritonavir 3 MO SYMTUZA 5 MO VIRACEPT 5 MO


45


Anti-influenza Agents oseltamivir phosphate caps, oral susp 3 MO RELENZA DISKHALER 3 QL (120 EA per 365 days) MO rimantadine hydrochloride 4 MO

Antiherpetic Agents acyclovir sodium inj 50mg/ml 4 B/D acyclovir caps, susp, tabs 2 MO acyclovir oint 4 QL (30 GM per 30 days) MO famciclovir tabs 500mg 2 QL (21 EA per 30 days) MO famciclovir tabs 125mg, 250mg 2 QL (60 EA per 30 days) MO valacyclovir hcl tabs 1gm 3 MO

valacyclovir hydrochloride tabs 500mg

3 MO


ANXIOLYTICS Anxiolytics, Other

buspirone hcl tabs 15mg, 30mg 2 MO buspirone hydrochloride tabs 10mg, 5mg, 7.5mg

2 MO

doxepin hcl caps 100mg, 10mg, 150mg, 50mg, 75mg

3 PA MO

doxepin hcl oral conc 3 PA MO doxepin hydrochloride caps 25mg 3 PA MO meprobamate 4 PA MO

Benzodiazepines alprazolam er tb24 0.5mg, 1mg 4 QL (30 EA per 30 days) MO alprazolam er tb24 3mg 4 QL (60 EA per 30 days) MO alprazolam er tb24 2mg 4 QL (90 EA per 30 days) MO alprazolam intensol oral soln conc 4 QL (300 ML per 30 days) MO alprazolam immediate release tabs 0.25mg, 0.5mg


alprazolam immediate release tabs 1mg, 2mg


chlordiazepoxide hcl caps 10mg, 5mg 4 QL (120 EA per 30 days) MO chlordiazepoxide hcl caps 25mg 4 QL (120 EA per 30 days) MO clorazepate dipotassium tabs 15mg 3 QL (180 EA per 30 days) MO clorazepate dipotassium tabs 3.75mg, 7.5mg


diazepam tabs 3 QL (120 EA per 30 days) PA MO diazepam oral conc 5mg/ml 3 QL (240 ML per 30 days) PA MO diazepam oral soln 4 QL (1200 ML per 30 days) PA MO

46


Drug name Drug tier Requirements/Limits diazepam inj 5mg/ml 4 QL (240 ML per 30 days) PA MO lorazepam oral conc 2 QL (150 ML per 30 days) MO lorazepam inj 2mg/ml, 4mg/ml 4 QL (150 ML per 30 days) MO lorazepam tabs 0.5mg 2 QL (120 EA per 30 days) MO lorazepam tabs 2mg 2 QL (150 EA per 30 days) MO lorazepam tabs 1mg 2 QL (180 EA per 30 days) MO oxazepam 4 QL (120 EA per 30 days) MO temazepam 4 QL (30 EA per 30 days) PA MO triazolam 4 QL (60 EA per 30 days) MO

BIPOLAR AGENTS Mood Stabilizers

lithium carbonate er tabs 4 MO lithium carbonate caps, tabs 1 MO LITHIUM ORAL SOLN 4 MO

BLOOD GLUCOSE REGULATORS Antidiabetic Agents

acarbose tabs 1 QL (90 EA per 30 days) MO BYDUREON BCISE 3 QL (3.4 ML per 28 days) MO BYDUREON PEN 3 QL (4 EA per 28 days) MO BYETTA INJ 5MCG/0.02ML 4 QL (1.2 ML per 30 days) MO BYETTA INJ 10MCG/0.04ML 4 QL (2.4 ML per 30 days) MO FARXIGA 3 QL (30 EA per 30 days) MO glimepiride 1 MO glipizide er 1 MO glipizide xl 1 MO glipizide/metformin hydrochloride 1 MO glipizide tabs 1 MO glyburide micronized tabs 3mg, 6mg 2 PA MO glyburide/metformin hydrochloride 2 PA MO glyburide tabs 2 PA MO GLYXAMBI 3 QL (30 EA per 30 days) MO JANUMET 3 QL (60 EA per 30 days) MO JANUMET XR TB24 1000MG; 100MG 3 QL (30 EA per 30 days) MO JANUMET XR TB24 1000MG; 50MG, 500MG; 50MG


JANUVIA 3 QL (30 EA per 30 days) MO JARDIANCE TABS 25MG 3 QL (30 EA per 30 days) MO JARDIANCE TABS 10MG 3 QL (60 EA per 30 days) MO JENTADUETO 3 QL (60 EA per 30 days) MO

47


JENTADUETO XR TB24 5MG; 1000MG


JENTADUETO XR TB24 2.5MG; 1000MG


KORLYM 5 PA LA MO metformin hcl er tb24 (generic

Glucophage XR) 500mg, 750mg 1 MO

metformin hcl er tb24 (generic Glumetza and Fortamet) 500mg


metformin hydrochloride tabs 1 MO miglitol 4 QL (90 EA per 30 days) MO nateglinide 1 MO

OZEMPIC INJ 2MG/1.5ML (0.25MG AND 0.5MG DOSE)

3 QL (1.5 ML per 28 days) MO

OZEMPIC INJ 2MG/1.5ML (1MG DOSE)


pioglitazone hcl-glimepiride 1 QL (30 EA per 30 days) MO pioglitazone hcl/metformin hcl 1 QL (90 EA per 30 days) MO pioglitazone hcl tabs 45mg 1 QL (30 EA per 30 days) MO

pioglitazone hydrochloride tabs 15mg, 30mg


repaglinide/metformin hydrochloride 1 QL (150 EA per 30 days) MO repaglinide tabs 0.5mg, 1mg 1 QL (120 EA per 30 days) MO repaglinide tabs 2mg 1 QL (240 EA per 30 days) MO RYBELSUS 3 QL (30 EA per 30 days) MO SYMLINPEN 120 5 QL (10.8 ML per 30 days) PA MO SYMLINPEN 60 5 QL (12 ML per 30 days) PA MO SYNJARDY XR TB24 25MG; 1000MG 3 QL (30 EA per 30 days) MO

SYNJARDY XR TB24 10MG; 1000MG, 12.5MG; 1000MG, 5MG; 1000MG


SYNJARDY TABS 5MG; 500MG 3 QL (120 EA per 30 days) MO SYNJARDY TABS 12.5MG; 1000MG,

12.5MG; 500MG, 5MG; 1000MG 3 QL (60 EA per 30 days) MO

TRADJENTA 3 QL (30 EA per 30 days) MO TRIJARDY XR TB24 10MG; 5MG;

1000MG, 25MG; 5MG; 1000MG 3 QL (30 EA per 30 days) MO

TRIJARDY XR TB24 5MG; 2.5MG; 1000MG

3 QL (60 EA per 30 days)

TRIJARDY XR TB24 12.5MG; 2.5MG; 1000MG



48


TRULICITY INJ 0.75MG/0.5ML, 1.5MG/0.5ML


VICTOZA 3 QL (9 ML per 30 days) MO XIGDUO XR TB24 10MG; 1000MG, 10MG; 500MG


XIGDUO XR TB24 2.5MG; 1000MG, 5MG; 1000MG, 5MG; 500MG


Glycemic Agents diazoxide susp 4 MO GLUCAGEN HYPOKIT 3 MO GLUCAGON EMERGENCY KIT 3 MO GLUCAGON EMERGENCY KIT FOR LOW BLOOD SUGAR

3 MO

GVOKE HYPOPEN 1-PACK 3 MO GVOKE HYPOPEN 2-PACK 3 MO GVOKE PFS 3 MO PROGLYCEM 4 MO

Insulins BASAGLAR KWIKPEN 3 MO FIASP 3 MO FIASP FLEXTOUCH 3 MO FIASP PENFILL 3 MO

HUMULIN R U-500 (CONCENTRATED)

5 B/D MO

HUMULIN R U-500 KWIKPEN 5 MO LEVEMIR 3 MO LEVEMIR FLEXTOUCH 3 MO

NOVOLIN 70/30 (BRAND RELION NOT COVERED)

3 MO

NOVOLIN 70/30 FLEXPEN 3 MO NOVOLIN N (BRAND RELION NOT

COVERED) 3 MO

NOVOLIN N FLEXPEN 3 MO NOVOLIN R (BRAND RELION NOT

COVERED) 3 MO

NOVOLIN R FLEXPEN 3 MO NOVOLOG 3 MO NOVOLOG FLEXPEN 3 MO NOVOLOG MIX 70/30 3 MO


49


NOVOLOG MIX 70/30 PREFILLED FLEXPEN

3 MO

NOVOLOG PENFILL 3 MO SOLIQUA 100/33 PREFILLED PEN 3 QL (30 ML per 30 days) MO TRESIBA 3 MO TRESIBA FLEXTOUCH 3 MO XULTOPHY 100/3.6 PREFILLED PEN 3 QL (15 ML per 30 days) MO


BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS Anticoagulants

COUMADIN TABS 3 MO ELIQUIS STARTER PACK 3 QL (74 EA per 30 days) MO ELIQUIS TABS 2.5MG 3 QL (60 EA per 30 days) MO ELIQUIS TABS 5MG 3 QL (74 EA per 30 days) MO enoxaparin sodium 4 MO fondaparinux sodium 4 MO FRAGMIN INJ 4 MO HEPARIN SODIUM/D5W INJ 25000UNIT/500ML, 20000UNIT/500ML

4

heparin sodium/d5w inj 5%; 100unit/ ml

4

heparin sodium/dextrose inj 5%; 25000unit/250ml

4

HEPARIN SODIUM/NACL 0.45% INJ 12500UNIT/250ML, 25000UNIT/500ML

3

heparin sodium/nacl 0.45% inj 25000unit/250ml

3

heparin sodium inj 5000unit/0.5ml, 5000unit/ml

3

heparin sodium inj 10000unit/ ml, 1000unit/ml, 20000unit/ml, 5000unit/0.5ml, 5000unit/ml

3 MO

jantoven 1 MO PRADAXA 4 QL (60 EA per 30 days) MO warfarin sodium tabs 1 MO XARELTO STARTER PACK 3 QL (51 EA per 30 days) MO XARELTO TABS 10MG, 15MG, 20MG 3 QL (30 EA per 30 days) MO XARELTO TABS 2.5MG 3 QL (60 EA per 30 days) MO

50

Drug name Drug tier Requirements/Limits Blood Formation Modifiers

anagrelide hydrochloride 3 MO ARANESP ALBUMIN FREE INJ 60MCG/0.3ML

4 QL (1.2 ML per 28 days) PA

ARANESP ALBUMIN FREE INJ 10MCG/0.4ML, 40MCG/0.4ML


ARANESP ALBUMIN FREE INJ 25MCG/0.42ML


ARANESP ALBUMIN FREE INJ 25MCG/ML, 40MCG/ML, 60MCG/ML

4 QL (4 ML per 28 days) PA

ARANESP ALBUMIN FREE INJ 500MCG/ML










ARANESP ALBUMIN FREE INJ 100MCG/ML, 200MCG/ML, 300MCG/ML


azacitidine 5 B/D PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML

3 PA

PROCRIT INJ 20000UNIT/ML, 40000UNIT/ML

5 PA

PROMACTA POWDER PACK 25MG 5 QL (180 EA per 30 days) PA PROMACTA POWDER PACK 12.5MG 5 QL (360 EA per 30 days) PA LA PROMACTA TABS 12.5MG, 25MG 5 QL (30 EA per 30 days) PA LA PROMACTA TABS 50MG, 75MG 5 QL (60 EA per 30 days) PA LA ZARXIO 5 PA

Hemostasis Agents tranexamic acid tabs 3 QL (30 EA per 30 days) MO tranexamic acid inj 4

Platelet Modifying Agents aspirin/dipyridamole 3 QL (60 EA per 30 days) MO BRILINTA 4 MO cilostazol 1 MO


51


Drug name Drug tier Requirements/Limits clopidogrel tabs 300mg 1 QL (2 EA per 365 days) MO clopidogrel tabs 75mg 1 QL (30 EA per 30 days) MO dipyridamole tabs 4 PA MO prasugrel 4 MO

CARDIOVASCULAR AGENTS Alpha-adrenergic Agonists

clonidine hcl weekly patch 3 QL (8 EA per 28 days) MO clonidine hydrochloride tabs 2 MO guanfacine hcl 4 PA MO methyldopa tabs 250mg, 500mg 4 PA MO midodrine hcl 4 MO NORTHERA CAPS 200MG, 300MG 5 QL (180 EA per 30 days) PA LA NORTHERA CAPS 100MG 5 QL (90 EA per 30 days) PA LA

Alpha-adrenergic Blocking Agents doxazosin mesylate tabs 2 MO prazosin hcl caps 1mg, 5mg 3 MO prazosin hydrochloride caps 2mg 3 MO terazosin hcl caps 10mg, 1mg, 5mg 1 MO terazosin hydrochloride caps 2mg 1 MO

Angiotensin II Receptor Antagonists amlodipine/olmesartan medoxomil 4 QL (30 EA per 30 days) MO amlodipine/valsartan 1 QL (30 EA per 30 days) MO amlodipine/valsartan/hctz tabs 10mg; 12.5mg; 160mg, 10mg; 25mg; 160mg, 10mg; 25mg; 320mg, 5mg; 25mg; 160mg


amlodipine/ valsartan/hydrochlorothiazide tabs 5mg; 12.5mg; 160mg


candesartan cilexetil 1 QL (30 EA per 30 days) MO candesartan cilexetil/hydrochlorothiazide tabs 32mg; 12.5mg, 32mg; 25mg


candesartan cilexetil/hydrochlorothiazide tabs 16mg; 12.5mg


EDARBI 4 QL (30 EA per 30 days) ST MO EDARBYCLOR 4 QL (30 EA per 30 days) ST MO eprosartan mesylate 1 QL (30 EA per 30 days) irbesartan 1 QL (30 EA per 30 days) MO

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*You can find information on what the symbols and abbreviations on this table mean by going to

page 8.

irbesartan/hydrochlorothiazide 1 QL (30 EA per 30 days) MO losartan potassium/ hydrochlorothiazide


losartan potassium tabs 100mg 1 QL (30 EA per 30 days) MO losartan potassium tabs 25mg, 50mg 1 QL (60 EA per 30 days) MO olmesartan medoxomil/amlodipine/ hydrochlorothiazide


olmesartan medoxomil/ hydrochlorothiazide


olmesartan medoxomil tabs 3 QL (30 EA per 30 days) MO telmisartan 1 QL (30 EA per 30 days) MO telmisartan/amlodipine 1 QL (30 EA per 30 days) MO telmisartan/hydrochlorothiazide 1 QL (30 EA per 30 days) MO valsartan/hydrochlorothiazide 1 QL (30 EA per 30 days) MO valsartan tabs 320mg 1 QL (30 EA per 30 days) MO valsartan tabs 160mg, 40mg, 80mg 1 QL (60 EA per 30 days) MO

Angiotensin-converting Enzyme (ACE) Inhibitors benazepril hcl/hydrochlorothiazide 1 MO benazepril hcl tabs 10mg, 40mg, 5mg 1 MO benazepril hydrochloride tabs 20mg 1 MO captopril/hydrochlorothiazide 1 MO captopril tabs 2 MO enalapril maleate/ hydrochlorothiazide

1 MO

enalapril maleate tabs 1 MO fosinopril sodium 1 MO

fosinopril sodium/hydrochlorothiazide

1 MO

lisinopril/hydrochlorothiazide 1 MO lisinopril tabs 1 MO moexipril hcl 1 MO perindopril erbumine 2 MO quinapril hcl tabs 20mg, 40mg, 5mg 1 MO quinapril hydrochloride tabs 10mg 1 MO quinapril/hydrochlorothiazide 2 MO ramipril 1 MO trandolapril 1 MO trandolapril/verapamil hcl er 1 MO


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Antiarrhythmics amiodarone hcl inj 50mg/ml,

900mg/18ml 4

amiodarone hcl tabs 400mg 2 MO amiodarone hcl inj 150mg/3ml, 450mg/9ml

4

amiodarone hydrochloride tabs 100mg, 200mg

2 MO

disopyramide phosphate caps 4 PA MO dofetilide 4 flecainide acetate 3 MO lidocaine hcl in d5w inj 4mg/ml 4

lidocaine hcl inj 100mg/5ml, 50mg/5ml

4

MULTAQ 4 MO NORPACE CR 4 MO pacerone tabs 100mg, 200mg, 400mg 2 propafenone hcl tabs 3 MO propafenone hydrochloride er 4 MO quinidine sulfate tabs 2 MO sorine 2 sotalol hcl 2 MO sotalol hcl (af) tabs 160mg 2 MO sotalol hcl (af) tabs 120mg, 80mg 2 MO

Beta-adrenergic Blocking Agents acebutolol hcl caps 2 MO acebutolol hydrochloride caps 400mg 2 MO atenolol/chlorthalidone 3 MO atenolol tabs 1 MO betaxolol hcl tabs 10mg, 20mg 3 MO bisoprolol fumarate 2 MO

bisoprolol fumarate/hydrochlorothiazide

2 MO

BYSTOLIC TABS 10MG, 2.5MG, 5MG 4 QL (30 EA per 30 days) MO BYSTOLIC TABS 20MG 4 QL (60 EA per 30 days) MO carvedilol phosphate caps 4 QL (30 EA per 30 days) MO carvedilol tabs 1 MO labetalol hydrochloride tabs 3 MO labetalol hydrochloride inj 5mg/ml 4 MO


54


metoprolol succinate er tabs 2 MO metoprolol tartrate tabs 1 MO metoprolol tartrate cartridge inj 1mg/ ml

4

metoprolol tartrate vial inj 5mg/5ml 4 MO metoprolol/hydrochlorothiazide 3 MO nadolol/bendroflumethiazide 3 MO nadolol tabs 20mg, 40mg, 80mg 4 MO pindolol tabs 3 MO

propranolol hcl er caps cp24 120mg, 160mg

4 MO

propranolol hcl oral soln 3 MO propranolol hcl inj 4 propranolol hcl tabs 40mg 3 MO

propranolol hydrochloride er caps 60mg, 80mg

4 MO

propranolol hcl tabs 10mg, 20mg, 60mg, 80mg

3 MO

propranolol/hydrochlorothiazide 2 MO timolol maleate tabs 10mg, 20mg,

5mg 1 MO

Calcium Channel Blocking Agents afeditab cr tb24 30mg 3

amlodipine besylate/atorvastatin calcium

1 MO

amlodipine besylate/benazepril hydrochloride


amlodipine besylate tabs 1 MO cartia xt 2 dilt-xr 2 MO diltiazem cd cp24 360mg 2 MO diltiazem cd cp24 180mg 2 diltiazem cd cp24 120mg 2 MO

diltiazem hcl er caps, tabs cp24 120mg, 180mg, 240mg, 300mg,

420mg

2 MO

diltiazem hcl er caps, tabs cp12, tb24 2 MO diltiazem hcl tabs 2 MO

diltiazem hcl inj 100mg, 125mg/25ml, 50mg/10ml

4


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diltiazem hydrochloride er 2 MO diltiazem hydrochloride inj 25mg/5ml 4 felodipine er 4 MO isradipine 2 MO matzim la 2 MO nicardipine hcl caps 4 MO nifedical xl tb24 60mg 3 nifedipine er 3 MO nimodipine caps 4 MO nisoldipine er 4 MO NYMALIZE SOLN 60MG/20ML, 6MG/ ML

5

taztia xt 2 tiadylt er cp24 120mg, 180mg,

240mg, 300mg, 360mg 2

tiadylt er cp24 420mg 2 MO verapamil hcl er caps, tabs cp24

100mg, 120mg, 180mg, 240mg, 300mg

2 MO

verapamil hcl er caps, tabs tbcr 2 MO verapamil hcl sr cp24 120mg, 180mg,

240mg 2 MO

verapamil hcl sr cp24 360mg 3 MO verapamil hcl sr tbcr 240mg 2 MO verapamil hcl tabs 40mg, 80mg 1 MO verapamil hydrochloride er cp24 2 MO verapamil hcl tabs 120mg 1 MO verapamil hydrochloride in

2020 comprehensive formulary - aetna · 8/1/2020 · coverage of the drug during the 2020 coverage...

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